人工肱骨头置换术对肩关节疼痛的缓解效果较好，但人工肱骨头置换术目前仍存在较多尚未解决的问题，缺乏长期随访结果，因此选择时需要慎重。应根据患者的具体情况作出个性化选择，对于年龄偏年轻，骨质条件较好的患者，肱骨近端锁定钢板内固定应考虑为首选。对于肱骨近端三或四部分骨折的老年患者，尤其是伴有明显骨质疏松的老年患者，人工肱骨头置换仍是最佳选择。肱骨头置换术治疗复杂肱骨近端骨折的适应证为： ① 老年患者肱骨头劈裂骨折；② Neer四部分骨折伴肱骨头脱位；③ 部分老年的三或四部分骨折伴骨质疏松；④ 老年患者发生严重的肱骨头压缩骨折，累及关节面﹥40％；⑤ 年龄﹥70岁。本组患者均为Neer四部分骨折伴肱骨头脱位，术后均获得有效减轻疼痛，重建关节功能。通过治疗，我们体会如下：① 术中选择适当大小的肱骨头假体并尽量标准安放，适当的后倾角度40°左右，外旋角20°左右，同时假体高度要适当，笔者建议假体最高点距离喙突10mm左右（容纳1指）为宜，过高则易发生撞击综合征，过低则易出现半脱位。尽量采用骨水泥型人工肱骨头假体增加稳定性。② 术中应重视肩袖的重建及大小结节等组织结构重建，在显露骨折断端时术者应始终注意保护大、小结节与附着肌肉的连续性不被破坏。大结节的愈合情况是影响人工肱骨头置换术后肩关节功能恢复的因素之一。③ 注意大结节的解剖重建是人工肱骨头置换术的关键。人工肱骨头置换术后的关节康复锻炼十分重要。但大结节重建患者应适当推迟术后开始被动功能锻炼的时间。
Humeral head replacement for the treatment of proximal humerus fracture of elderly patients（人工肱骨头置换治疗老年肱骨近端骨折）
zhang daokun. Department of Orthopedics, Affiliated Hospital of Shandong Academy of Medical Sciences
Proximal humerus fracture have a high incidence in elderly patients with osteoporosis, many patients accompany dislocation of the humeral head.Plate fixation are reported to has been linked to pain, poor function,and instability, Replacement of humeral head prosthesis produces better clinical outcomes than open reduction and internal fixation in patients with comminuted proximal humeral fractures, and can promote the short-term functional recovery of the shoulder with minimal surgical complications. humeral head replacement is a reliable method used to alleviate pain and improve functionin patients with comminuted proximal humerus fracture of elderly patients
all operations were thrugh anterior approach, cut the skin and joint capsule,fully exposed the fracture and the dislocated humeral head. Took out the humeral head,expaned the canal,measured the size of prosthesis, rinsed the canal fully,injected the bone cement in proximal humeruscanal,and finally implanted the appropriate size artificial humeral head.the prosthesis must be inclined angle Of tilt to backword abult 40° and external rotation angle of aboult 20°.cut the Autologous humeral head into many block strip bones,which were implanted around the prosthesis,the greater tubercle and lesser tubercle were fixed around the prosthesis by Steel wire or Vicryl silk. The Shoulder were suspended after operation, shoulder exercise were begined about 1 week after operation.
Humeral head replacement has better effect in pain relief than Plate ,which can take early activity. but the humeral head replacement surgery there are still many unresolved issues, the long-term follow-up results are little, so which is still need choose carefully.Personalized choice should be made according to the specific circumstances such as the patient's age ,bone condition. For elderly patients with three or four-part proximal humerus fractures, especially with significant osteoporosis for elderly patients,humeral head replacement is still the best choice.
The surgery indications for Humeral head replacement may be as follows:① serious Cleavage fractures of humeral head for elderly patients; ② Neer type IV (four-part )fracture and with dislocation of humeral head; ③Neer type III or IV( three or four-part )fractures associated with serious osteoporosis in old age; ④ elderly patients with severe compression fracture of the humeral head, the Humeral head surface > 40%;⑤Neer typeIV (four-part )fracture ,and age> 70 years.
The patients of our study group were all Neer type IV (four-part ) fracture with dislocation of the humeral head, aged 65 to 78 years. all patients acquired goog effective in relieving pain after surgery, and aquired good reconstruction of joint function.
By the study ,lessons are learned as following: ①select appropriate size humeral head,accurate prosthesis location.backward angle of about 40 °, external rotation angle of approximately 20 °. the height of the prosthesis, we suggest the best distance between the prosthesisand the highest point of the lower edge of the acromion be about 10mm (or can holding a finger),which may be appropriate.the distance was lager may cause acromion strike,and smaller may be cause subluxation.② should pay attention to the reconstruction of Rotator cuff and reducing damage of the structure of the organization shuch as the greater tubercle , lesser tubercle,and the continuity of muscle attachment. ③The reconstruction of greater tubercle is one of the main factors that affect the function recovery for shoulder after the humeral head replacement.
humeral head replacement in anatomical and overlapping reconstruction,which has the greater tuberosity biomechanical stability after fixation, the results showed the anatomical reconstruction group had the greater tuberosity stability than the overlapping reconstruction group, and pointed out the anatomic reconstruction of large nodules is the key of artificial humeral head replacement. We believe that the distance between the greater tuberosity tip and humeral head top articular surface is not more than 10mm, the humeral head was cut into Small pieces and were grafted into the bone defect . and were banded around the large nodules, to increase the healing opportunity of bone and prosthesis, functional exercise time after operation was properly delayed, maybe reduce the absorption of bone nodules.